Facial hirsutism: A common condition worth treating seriously

Hirsutism affects between 5 and 15% of women (Azziz 2003) across all ethnic backgrounds. Facial hirsutism is usually the result of an underlying adrenal, ovarian, or central endocrine abnormality often due to polycystic ovary syndrome (PCOS), but may also be related to constitutional or drug induced menopause. Although rarely caused by a serious illness, facial hirsutism is associated with clinically significant levels of anxiety and emotional distress in women, most likely due to social stigma. The aim of medical treatment is to rectify any causal hormonal balance, slow down or stop excessive hair growth, and improve the aesthetic appearance of hirsutism, thereby positively affecting the patient’s quality of life (Blume 2008). Because it is treated as a taboo in UK culture, patients may be reluctant to discuss facial hirsutism with their doctor unless prompted. In the UK, hirsutism is also referred to as excessive facial hair or unwanted facial hair.

Hirsutism and unwanted facial hair vs. Hypertrichosis

Hirsutism is defined as the presence of excess terminal (coarse) hairs in females in androgen-dependent areas. Typically they exhibit patterns of adult male hair growth on the upper lip, chin, chest, abdomen (tummy), or back. Facial hair is usually the main concern for women. The clinical designation is assigned when a woman is assessed as having a Ferriman-Gallwey (F-G) score of 8 or more (Azziz 2003). The term “unwanted facial hair” is characterised by facial hair growth that may have a Ferriman-Gallwey (F-G) score below 8, yet is nonetheless coarser, longer, or more profuse than the woman considers normal for her age. Unwanted facial hair can be defined as having a hair density of at least five hairs/cm2 on both the chin and the upper lip (Blume 2008, Wolf 2007). Depending on the definition and the underlying data, estimates indicate that approximately 40% of women have some degree of unwanted facial hair (Blume 2007).

Hypertrichosis differs from hirsutism in that the hypertrichotic patient can be a man or woman who presents with an excess of hair at any site on the body (even in non-androgen-dependent regions) (Trueb 2002).

Hirsutism: Types

Androgenic hirsutism is the most common form of hirsutism and is usually the result of an underlying adrenal, ovarian, or central endocrine abnormality (Blume 2008).

Constitutional/Idiopathic hirsutism is diagnosed when no underlying disease or abnormalities can be determined. Up to 15% of hirsute women have idiopathic hirsutism (with no evidence of elevated androgen levels) (Azziz 2003).

Iatrogenic/Drug-related hirsutism is a consequence of taking medicine that has side effects resulting in hirsutism or hypertrichosis (Rittmaster 1997).

Hirsutism: Causes

Polycystic Ovary Syndrome – PCOS (androgenic hirsutism) affects between 3.5% and 11% of women, irrespective of ethnic background (Knochenhauer 1998). Of women with PCOS, 90% have facial hirsutism (Cronin 1998). It is estimated that 74% of women with hirsutism suffer from PCOS (Azziz 2004).

Side-effects of drug therapies such as ciclosporin, diazoxide, glucocorticoids, phenytoin and minoxidil can be associated with hirsutism and unwanted facial hair (Rittmaster 1997).

Menopause can also be a factor in hirsutism and/or unwanted facial hair due to elevated free-androgen levels and hormonal imbalance (Legro 2002).

Other pathologies – Although rare, hirsutism can also be related to congenital adrenal hyperplasia, benign and malignant androgen-producing tumours of the ovaries or the adrenal gland, hyperprolactinaemia, Cushing’s disease, or acromegaly (Blume 2008). Obesity can also cause changes in how hormones are regulated, and so lead to hirsutism (Rittmaster 1997).

Facial hirsutism: Impact on quality of life

Unwanted facial hair is a problem that has both physical and psychological effects (Lipton 2006). Women with unwanted facial hair have significantly higher scores of somatisation than non-hirsute women (Blume 2007) and 27% of hirsute patients have been found to have psychiatric disturbances (Barth 1993). While the level of bother caused by facial hirsutism varies among women, it has been found that the condition can have a profound negative impact on a woman’s confidence, self-esteem (Azziz 2003) and overall quality of life (Sonino 1993).

Facial hirsutism assessment: Clinical vs. subjective

It is important to realise that there is not necessarily a correlation between the physician’s and the patient’s assessment of unwanted facial hair. Studies indicate that the level of facial hair regarded as socially unacceptable by the general population and distressing to those who suffer from the condition is below that which many physicians would classify as clinical facial hirsutism (Wolf 2007). Therefore, patient grading may be considered more relevant since it is likely to reflect the total burden of hair (Smith 2006).

The Impact of facial hair on women’s lives  (Lipton 2006)

Hirsutism has well-recognised psychological and social consequences (Lipton 2006)